Provider Demographics
NPI:1700834769
Name:MIMS, CAROLYN OLIVE (CRNA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:OLIVE
Last Name:MIMS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:SC
Mailing Address - Zip Code:29477-2024
Mailing Address - Country:US
Mailing Address - Phone:843-563-3247
Mailing Address - Fax:
Practice Address - Street 1:204 CHARLES ST.
Practice Address - Street 2:
Practice Address - City:ST. GEORGE
Practice Address - State:SC
Practice Address - Zip Code:29477
Practice Address - Country:US
Practice Address - Phone:843-563-3247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21281367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
227714Medicare UPIN